Health inspection·March 21, 2024

F 0569 Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. Level of Harm - Minimal harm or potential for actual harm Based on review of resident funds records and staff interview, the facility failed to ensure resident's funds were maintained under the Medicaid limit. This affected three residents (#02, #25, and #47) of five residents reviewed for personal funds. The facility census was 101. Residents Affected - Few Findings include: 1. Review of Resident #02's personal funds revealed a balance of $,3390.68 as of 03/20/24. The balance on 09/30/23 was $2,937.52. The facility had sent a Resident Fund Balance Notification on 01/03/24 to the resident's representative indicating they were to notify the Social Worker within the next seven days to discuss ways to assure continuance of Medicaid benefits. No record of discussion with the representative was located in the medical record. 2. Review of Resident #25's personal funds revealed a balance of $6,790.21 as of 03/20/24. The balance on 09/30/23 was $7,481.77. The facility had sent a Resident Fund Balance Notification on 01/03/24 to the resident's representative indicating they were to notify the Social Worker within the next seven days to discuss ways to assure continuance of Medicaid benefits. No record of discussion with the representative was located in the medical record. 3. Review of Resident #47's personal funds revealed a balance of $2,533.19 as of 03/20/24. The balance on 09/30/23 was $3,638.48. The facility had sent a Resident Fund Balance Notification on 01/03/24 to the resident's representative indicating they were to notify the Social Worker within the next seven days to discuss ways to assure continuance of Medicaid benefits. No record of discussion with the representative was located in the medical record. Interview on 03/20/24 at 3:55 P.M. with [NAME] President of Operations #360 verified the facility had not followed through with ensuring the resident's funds were maintained at or below the allowable limit set by Medicaid. Page 1 of 5 365830 365830 03/21/2024 Bryan Healthcare and Rehabilitation 1104 Wesley Avenue Bryan, OH 43506

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, medical record reviews, resident and staff interviews, and review of the facility policy, the facility failed to timely address the resident's skin impairments and failed to implement physician orders routinely to address the resident's skin conditions. This affected two (#21 and #68) of four residents reviewed for skin integrity. The facility census was 101. Residents Affected - Few Findings include: 1. Review of Resident #68's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included type II diabetes mellitus and coronary artery disease. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #68 had intact cognition. Resident #68 required set-up assistance from staff with activities of daily living, had no refusal of treatment, was independently mobile utilizing a walker or wheelchair, and was at risk for pressure ulcer development with no current skin breakdown. Review of the physician order dated 11/01/23 revealed an order to apply (Tubigrips) compression stockings to the bilateral lower extremities every day and night shift for edema. On 03/14/24, a physician order was implemented for the application of Clobetasol Propionate External Cream 0.05 % (Clobetasol Propionate) to be applied to the left posterior calf topically two times a day for dermatitis for seven days. Review of the treatment administration record (TAR) revealed the physician orders were signed as applied at morning and bedtime. Review of the nursing plan of care (POC) dated 02/27/24 revealed the POC was revised to address Resident #68's risk for impairment to skin integrity related to occasional incontinence, diabetes, anticoagulant use, and multiple comorbidities. Interventions included to follow physician orders for treatment of skin impairments and refer to the electronic Treatment Administration Record (eTAR) for specifics. Provide pain management with treatments as needed. Keep skin clean and dry. Use lotion on dry skin. Observe skin daily with care activities. Report any changes in coloration, integrity to nurse. Observation and interview on 03/18/24 at 8:01 P.M. revealed Resident #68 had an area of red skin excoriation to the back of the left leg and bilateral lower extremity edema. Resident #68 stated he wears compression stockings to the lower extremities. However, staff do not apply and the resident attempts to apply himself. The resident also stated he has an ointment that was to be applied to the back of the left leg, which does not get applied consistently. Additional observation on 03/19/24 at 12:30 P.M. revealed Resident #68 was dressed and seated in a wheelchair. Resident #68 did not have the compression stockings applied and stated the ointment had not been applied to the left calf (back of leg). On 03/19/24 at 12:46 P.M., an interview with Licensed Practical Nurse (LPN) #322 during a review of treatment administration records (TAR) revealed she had recorded (signed off) the ointment to Resident #68's leg as applied and also the compression stockings as applied for the morning administration on 03/19/24. However, LPN #322 verified the ointment and compression stockings had not been applied as ordered. 365830 Page 2 of 5 365830 03/21/2024 Bryan Healthcare and Rehabilitation 1104 Wesley Avenue Bryan, OH 43506

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 03/19/24 at 1:31 P.M., observation with LPN #322 and #361 and Certified Nurse Practitioner (CNP) #361 assessed Resident #68 with two plus bilateral lower extremity edema. LPN #322 went on to apply the Clobetasol Propionate External Cream 0.05 % to the left posterior calf. Review of the facility's Skin Alterations Non-Pressure Guidance revised 03/2023 revealed skin alteration treatments will be initiated as ordered by the physician or physician extender. 2. Review of Resident #21's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included type II diabetes mellitus, venous insufficiency, chronic kidney disease, morbid obesity, and lymphedema. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #21 had intact cognition, dependent on staff for the completion of activities of daily living, and required substantial to maximal assistance from staff with bed mobility. Resident #21 was at risk for pressure ulcer development with no current skin breakdown. Review of the plan of care dated 06/09/23 revealed Resident #21 had peripheral vascular disease (PVD) related to diabetes mellitus and heart disease. Interventions included inspect feet daily and daily change of hosiery and socks. Monitor/document/report as needed (PRN) any signs or symptoms (s/sx) of complications of extremities: coldness of extremity, pallor, rubor, cyanosis and pain. Monitor/document/report PRN any s/sx of skin problems related to PVD: redness, edema, blistering, itching, burning, bruises, cuts, and other skin lesions. Review of the nursing plan of care dated 03/18/24 revealed Resident #21 was at risk for skin breakdown due to decreased mobility, incontinence of urine, chronic redness between toes, complaints of itchy, dry skin, diabetes, mellitus, lymphedema, PVD, and obesity. Skin assessment weekly. Treatments as ordered. Review of the physician's orders dated 03/18/24 revealed there were no orders for any treatment to Resident #21's thighs or shins. Interview on 03/18/24 at 7:17 P.M. with Resident #21 revealed she had a skin irritation to the lower extremities and no treatment had been initiated. Observation on 03/20/24 at 9:00 A.M. with State Tested Nurse Aide (STNA) #235 noted Resident #21 with bilateral red shins and inner posterior thighs were reddened. STNA #235 stated Resident #21 had the reddened tissue to the thighs for approximately one week and the bilateral shins for two months. STNA #235 was unaware if a treatment to the skin had been obtained. Interview on 03/20/24 at 9:19 A.M. with Licensed Practical Nurse (LPN) #276 was unaware of Resident #21's excoriation or rash to inner lower thigh or treatment to the bilateral shins. LPN #276 verified there were no treatments ordered in the electronic treatment administration record (eTAR) to to address the bilateral shins or inner thighs. LPN #276 obtained measurements to include the following; right thigh 20.0 centimeters (cm) long by (x) 12.0 cm wide and left thigh 15.0 cm x 12.0 cm with deep red tissues. Review of the Skin Alterations Non-Pressure Guidance revised 03/2023 revealed ways to identify skin alterations included during showers, bed baths and completing incontinence care, repositioning, dressing, undressing and activities of daily living care. Skin alteration treatments will be initiated 365830 Page 3 of 5 365830 03/21/2024 Bryan Healthcare and Rehabilitation 1104 Wesley Avenue Bryan, OH 43506

F 0684 Level of Harm - Minimal harm or potential for actual harm as ordered by the physician or physician extender. Skin assessment will be initiated, and the area will be monitored routinely for healing progress of need to change treatment orders. Investigation into causal factors of skin alteration. Residents Affected - Few 365830 Page 4 of 5 365830 03/21/2024 Bryan Healthcare and Rehabilitation 1104 Wesley Avenue Bryan, OH 43506

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, staff interview, and review of the facility policy, the facility failed to remove molded foods from the refrigerator, store food off the floor, and discard expired foods. This had the potential to affect all 100 residents who received food from the kitchen. There was one resident (#84) identified by the facility as not receiving food from the kitchen. The facility census was 101. Findings include: Observation and interview on 03/18/24 from 6:20 P.M. through 6:45 P.M. during the initial kitchen tour with [NAME] #310 revealed a partially aluminum foil covered metal pan approximately 11 inches by 15 inches filled with slider type sandwiches, 15 boxes of frozen food items sitting on the floor of the walk-in freezer, 15 boxes of produce items sitting on the floor in the walk-in cooler, four boxes of bread and buns sitting on the floor next to the bread cooler, and two containers of molded strawberries in the walk-in cooler. Cook #310 verified the partially covered sliders, the boxes of frozen food items in the walk-in freezer sitting on the floor, the boxes of produce sitting on the floor in the walk-in cooler, the four boxes of bread and buns sitting on the floor, and the containers of molded strawberries in the walk-in cooler. [NAME] #310 stated the facility received delivery of products earlier in the day and the products were not put away. [NAME] #310 stated the delivery of products arrived between 5:00 A.M. to 8:00 A.M. earlier in the day. [NAME] #310 stated the sliders were served at an event on 03/14/24, four days prior. Review of the facility policy titled Food Storage Guidelines revised 05/2023 revealed sufficient storage facilities will be provided to keep foods safe, wholesome, and by methods designed to prevent contamination or cross contamination. Food items will be stored on shelves. Food should be stored a minimum of six inches above the floor. Leftover food should be stored in covered containers or wrapped carefully and securely and clearly labeled. All foods should be stored off the floor. 365830 Page 5 of 5